TABLE | College | |---| | The University of Western Australia | TABLE | Logo Name | Logo | |---|---| | Perth Oral Medicine & Dental Sleep Centre |  | | Perth Childrens Hospital | | | Perigold | | | Oral Medicine Australia | | | Dental Sleep Society Western Australia | | | Australian Dental Association | | | Australasian Dental Sleep Association | | The University of Western Australia #### Affiliated Organizations - Perth Oral Medicine & Dental Sleep Centre - Perth Childrens Hospital - Perigold - Oral Medicine Australia - Dental Sleep Society Western Australia - Australian Dental Association - Australasian Dental Sleep Association **Ramesh Balasubramaniam OAM** **Associate Professor, Oral Medicine** UWA Dental School **The University of Western Australia** **Neither I nor my immediate family have any financial interests that would create a conflict of interest or restrict my independent judgment with regard to the content of this presentation.** #### Presenter Information **Ramesh Balasubramaniam OAM** Associate Professor, Oral Medicine UWA Dental School The University of Western Australia #### Conflict of Interest Disclosure Neither I nor my immediate family have any financial interests that would create a conflict of interest or restrict my independent judgment with regard to the content of this presentation. ## AGENDA 1. OCCLUSAL SPLINTS REVISITED 2. OCCLUSAL SPLINTS DESIGN SECRETS 3. MECHANISMS OF ACTION 4. SCIENTIFIC EVIDENCE FOR OCCLUSAL SPLINTS 5. TAKE HOME MESSAGE  #### Presentation Agenda 1. Occlusal Splints Revisited 2. Occlusal Splints Design Secrets 3. Mechanisms of Action 4. Scientific Evidence for Occlusal Splints 5. Take Home Message Flowchart diagram illustrating the presentation agenda. It features a vertical sequence of five blue rectangular blocks with white text, connected by downward-pointing gold arrows indicating progression. The steps are: 'OCCLUSAL SPLINTS REVISITED', 'OCCLUSAL SPLINTS DESIGN SECRETS', 'MECHANISMS OF ACTION', 'SCIENTIFIC EVIDENCE FOR OCCLUSAL SPLINTS', and 'TAKE HOME MESSAGE'.   Header banner with the title 'AGENDA' in white text on a brown background. Includes an 'RB' logo on the left. Flowchart diagram outlining the presentation agenda. It consists of five stacked rectangular blocks connected by yellow arrows pointing downwards. The sequence is: 1. OCCLUSAL SPLINTS REVISITED (Orange block), 2. OCCLUSAL SPLINTS DESIGN SECRETS (Blue block), 3. MECHANISMS OF ACTION (Blue block), 4. SCIENTIFIC EVIDENCE FOR OCCLUSAL SPLINTS (Blue block), and 5. TAKE HOME MESSAGE (Blue block). # OCCLUSAL SPLINTS REVISITED **Dr Norman William Kingsley** **(1829 – 1913)** **New York, USA** First to use “the occipital appliance” in 1866. First to publish on intraoral appliances for the TMJ (Dental Cosmos in 1877). The Glossary of Prosthoontic Terms: Ninth Edition. J Prosthet Dent. 2017 May;117(5S):e1-e105.   #### Pioneering Contributions of Dr. Norman William Kingsley Dr. Norman William Kingsley (1829 – 1913) of New York, USA, was a foundational figure in the development of dental appliances: - **1866:** First to utilize the "occipital appliance." - **1877:** First to publish research regarding intraoral appliances for the Temporomandibular Joint (TMJ) in *Dental Cosmos*. *Source: The Glossary of Prosthodontic Terms: Ninth Edition. J Prosthet Dent. 2017 May;117(5S):e1-e105.* Sepia-toned historical portrait of Dr Norman William Kingsley (1829–1913), a prominent figure in dental history. The image depicts an elderly man with white hair and a full mustache, wearing formal attire. A blue rounded-rectangular text box containing key biographical achievements of Dr Kingsley. It highlights that he was the first to use 'the occipital appliance' in 1866 and the first to publish on intraoral appliances for the TMJ in Dental Cosmos in 1877. # OCCLUSAL SPLINTS REVISITED ## Early concepts: **occlusal splint** for temporomandibular disorders and bruxism - Related occlusal disharmonies - Related skeletal discrepancies ## Treatment Goals: - **Occlusal disengagement** - **Restoring vertical dimension** - **TMJ repositioning** - **TMJ unloading** Klasser GD, Greene CS. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2009 Feb;107(2):212-23. #### Applications for TMD and Bruxism Occlusal splints are utilized to address temporomandibular disorders and bruxism, specifically targeting: - Related occlusal disharmonies - Related skeletal discrepancies #### Primary Treatment Objectives - **Occlusal disengagement:** Preventing adverse tooth contact. - **Restoring vertical dimension:** Establishing proper interarch distance. - **TMJ repositioning:** Aligning the joint structures. - **TMJ unloading:** Reducing pressure and stress on the joint components. *Source: Klasser GD, Greene CS. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2009 Feb;107(2):212-23.* **AGENDA** **OCCLUSAL SPLINTS REVISITED** **OCCLUSAL SPLINTS DESIGN SECRETS** **MECHANISMS OF ACTION** **SCIENTIFIC EVIDENCE FOR OCCLUSAL SPLINTS** **TAKE HOME MESSAGE**  #### Agenda - Occlusal Splints Revisited - Occlusal Splints Design Secrets - Mechanisms of Action - Scientific Evidence for Occlusal Splints - Take Home Message Flowchart-style diagram illustrating the agenda of a presentation on occlusal splints. The visual structure consists of five horizontal rectangular blocks arranged vertically with downward-pointing arrows connecting them to indicate sequence. From top to bottom: 1) Blue block labeled 'OCCLUSAL SPLINTS REVISITED', 2) Orange block labeled 'OCCLUSAL SPLINTS DESIGN SECRETS', 3) Blue block labeled 'MECHANISMS OF ACTION', 4) Blue block labeled 'SCIENTIFIC EVIDENCE FOR OCCLUSAL SPLINTS', and 5) Blue block labeled 'TAKE HOME MESSAGE'. A gold header bar at the top reads 'AGENDA'. # OCCLUSAL SPLINTS MATERIALS ```mermaid graph TD A[Occlusal Splints] --> B[CAD/CAM and 3D Printed] A --> C[Conventional] subgraph "Variations of Plastic" A end subgraph "Methodology" B C end subgraph "Hardness" D[Hard] E[Flexible] F[Semi-Flexible] G[Soft] end subgraph "Flexural Strengths" H[PMMA<br/>120-150mPa] I[Nylon<br/>50-70mPa] J[PEEK<br/>140-170mPA] K[Silicone-based<br/>5-15mPA] end B -.-> D D --- H E --- I F --- J G --- K ``` Courtesy of 3D Sleep Laboratory Courtesy of Digident Laboratory  #### Material Classification and Properties Occlusal splints are categorized by manufacturing method (Conventional vs. CAD/CAM and 3D Printed) and material hardness. - **Hard (PMMA)** - Flexural Strength: 120-150 mPa - **Semi-Flexible (PEEK)** - Flexural Strength: 140-170 mPa - **Flexible (Nylon)** - Flexural Strength: 50-70 mPa - **Soft (Silicone-based)** - Flexural Strength: 5-15 mPa A comprehensive educational figure on 'OCCLUSAL SPLINTS MATERIALS'. The visual includes a hierarchical diagram showing 'Occlusal Splints' branching into 'CAD/CAM and 3D Printed' vs. 'Conventional', then categorized by 'Hardness' (Hard, Flexible, Semi-Flexible, Soft) and corresponding 'Flexural Strengths' (PMMA 120-150mPa, Nylon 50-70mPa, PEEK 140-170mPA, Silicone-based 5-15mPA). To the right are photos of lab glassware (beaker with orange liquid, flask with green liquid), and at the bottom are images of physical occlusal splint examples (blue rigid, white flexible, beige semi-flexible, clear silicone) with captions: 'Courtesy of 3D Sleep Laboratory' and 'Courtesy of Digident Laboratory'. # FLAT PLANE STABILISATION SPLINT * **Maxillary or mandibular arch** - Uniformly occlude with opposing dentition. Turp et al. Clin Oral Investig 2004; 8:179-95. * **Canine vs No Canine Guidance** Denardin et al. Oral Surg Oral Med Oral Pathol Oral Radiol. 2023 Jan;135(1):51-6. Conti et al JADA 2006; 137:1108-1114. No Difference in TMD Symptom Reduction! <br> **Purpose:** * Joint stabilisation * Protect teeth * Redistribute occlusal forces * Relax elevator muscles * Decrease bruxism <br> Courtesy of Digident Laboratory Klasser & Romero Reyes (2023) Orofacial Pain: Guidelines for Assessment, Diagnosis, and Management 7<sup>th</sup> Ed. Quintessence Publishing   #### Design and Clinical Application - **Arch Placement:** Maxillary or mandibular arch; designed to uniformly occlude with opposing dentition. - **Guidance:** Research indicates no difference in TMD symptom reduction between designs with canine guidance versus those without canine guidance. #### Clinical Purpose - Joint stabilisation - Protection of teeth - Redistribution of occlusal forces - Relaxation of elevator muscles - Decrease in bruxism Clinical photo of a white, flat-plane stabilization splint (occlusal guard) resting on a surface. Caption below reads 'Courtesy of 3D Sleep Laboratory'. Clinical photo of a translucent blue dental splint showing the arch form. Caption above reads 'Courtesy of Digident Laboratory'. HARD SPLINT VS SOFT SPLINT Soft splints: No difference in TMD symptoms reduction. Cheaper, short-term alternative. Wright et al. J Orofac Pain. 1995 Spring;9(2):192-9. Truelove J Am Dent Assoc 2006;137:1099-1107. Increase EMG activity with soft splints. Increase sleep bruxism in short-term. Okeson JP. J Am Dent Assoc 1987;114:788-91. Most studies support use of hard occlusal splints. Stronger and easier to adjust.  #### Clinical Efficacy - **Soft Splints:** - No significant difference in TMD symptom reduction compared to hard splints. - Considered a cheaper, short-term alternative. - Associated with increased EMG activity and a short-term increase in sleep bruxism. - **Hard Splints:** - Supported by most studies. - Stronger and easier to adjust clinically. Comparative figure showing three visual elements: (1) a translucent soft splint on a blue textured background, demonstrating flexibility; (2) a close-up photo of a patient's face with the lower jaw in a slightly protruded position, illustrating the use of a splint; and (3) a hard occlusal splint on a dark surface, showing rigid structure. The images visually demonstrate the physical differences between soft and hard splints. **TRADITIONAL ANTERIOR BITE PLANE SPLINT** Variations of orthodontic (Hawley, Sved, Shore) appliance. * Palatal coverage horseshoe shape with occlusal platform covering 6-8 maxillary anterior teeth. **Advocates:** prevents teeth clenching. **Critics:** No posterior support - overeruption of posterior teeth and overloading the TMJs. Courtesy of A/Prof Sanjivan Kandasamy   #### Design Characteristics - Variations include orthodontic appliances such as Hawley, Sved, and Shore designs. - Features a horseshoe-shaped palatal coverage with an occlusal platform covering 6-8 maxillary anterior teeth. #### Clinical Perspectives - **Advocates:** Suggests the design prevents teeth clenching. - **Critics:** Note the lack of posterior support, which may lead to overeruption of posterior teeth and overloading of the TMJs. Clinical photograph showing the Traditional Anterior Bite Plane Splint appliance isolated against a white background. The device features a horseshoe-shaped palatal coverage made of clear acrylic with metal clasps for retention. Intraoral clinical photograph demonstrating the splint in use on a patient's upper jaw. The image shows the transparent occlusal platform covering the maxillary anterior teeth (covering 6-8 teeth as described) and the metal wire components engaging the posterior teeth. **MINI-ANTERIOR APPLIANCES** Variations of a theme that engages 2-4 incisors. Turp et al. Clin Oral Investig 2004; 8:179-95. **Advocates:** * **Disengages** the posterior teeth. * **Utilised** for TMDs, sleep bruxism, and headaches. **Systematic review:** **NTItss** may be useful for bruxism and TMD. * Reduction of jaw closing muscle activity. * Applications in acute pain and limited opening. Magnusson et al. Swed Dent J 2004;28:11-20. | | | :--- | | Mini Anterior Appliance | | Best Bite | | AMPS | | Lucia Jig | | NTItss | **MINI-ANTERIOR APPLIANCES**   #### Device Variations Mini-anterior appliances typically engage 2-4 incisors. Common variations include: - NTI-tss - Best Bite - AMPS - Lucia Jig #### Clinical Indications - **Function:** Disengages posterior teeth. - **Applications:** Utilized for TMDs, sleep bruxism, and headaches. - **Systematic Review Findings:** NTI-tss may be useful for bruxism and TMD by reducing jaw-closing muscle activity, particularly in cases of acute pain and limited opening. Clinical photo of an open human mouth displaying the anterior teeth. A white, custom-fitted dental appliance is visible attached to the upper incisors (central and lateral), demonstrating the physical application of a mini-anterior appliance as described in the text. Conceptual diagram illustrating variations of the Mini Anterior Appliance theme. It features a central dark blue circle labeled 'Mini Anterior Appliance' connected by curved blue lines to four surrounding satellite circles representing specific types: 'Best Bite', 'AMPS', 'Lucia Jig', and 'NTItss'. The diagram visually summarizes the relationship between the general category and its specific examples. <!--Mini-Anterior Appliances --> ### MINI-ANTERIOR APPLIANCES **Adverse Effects:** * **Posterior teeth overeruption** and **anterior openbite development.** * **Mandibular anterior teeth mobility** and **maxillary anterior teeth displacement.** * **Risk of swallowing** or **aspiration.** #### Potential Adverse Effects - **Occlusal Changes:** Posterior teeth overeruption and development of an anterior open bite. - **Dental Displacement:** Mandibular anterior teeth mobility and maxillary anterior teeth displacement. - **Safety Risks:** Risk of swallowing or aspiration of the small appliance. **Mini-Anterior Appliances** Scientific Evidence **No difference between NTItss and stabilisation appliance in TMD symptoms or headache.¹** **NTItss less effective than a flat plane stabilisation appliance for TMD.²** **No differences between AMPS device and stabilisation appliance for myogenous pain.³** **Thickness and elasticity of masseter muscle significantly decreased after NTItss among bruxers.⁵** **NTItss more effective than "full coverage appliance" for headache.⁴** * Flawed study: bleaching tray controls and statistics unclear ¹ **Jokstad A. et al. Acta Odontal Scand 2005;63:218-26.** ² **Magnusson T. et al. Swed Dent J 2004;28:11-20.** ³ **Al-Quran FAM, Kamal MS. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2006;101:741-7.** ⁴ **Shankland WE. Cranio 2001;19:269-78.** ⁵ **Yalcin ED, Aslan Ozturk EM. Cranio 2025;43(1):135-143.** #### Comparative Research Findings - **NTI-tss vs. Stabilisation Splints:** - No difference found in TMD symptoms or headaches in some studies. - Other research suggests NTI-tss is less effective than flat plane stabilisation appliances for TMD. - **AMPS vs. Stabilisation Splints:** No differences found for myogenous pain. - **Muscle Effects:** Thickness and elasticity of the masseter muscle significantly decreased after NTI-tss use among bruxers. - **Headache Treatment:** One study suggested NTI-tss was more effective than full coverage appliances, though the study was noted to have flaws regarding controls and statistics. **ANTERIOR REPOSITIONING SPLINT** **Positions the mandible anteriorly with anterior guiding ramp.** **Advocates:** * “Recapture” the disc from clicking, catching or locking and pain. * **Positions disc tempor. by taking pressure off.** * Followed by comprehensive dental and surgical procedures. Farrar J Prosthet Dent 1972;28:629-36. Tesco et al. Cranio 2004;22:209-219.  #### Mechanism and Goals - **Function:** Positions the mandible anteriorly using an anterior guiding ramp. - **Advocates' View:** - Intended to "recapture" the disc in cases of clicking, catching, or locking. - Positions the disc temporarily by reducing pressure. - Often intended as a precursor to comprehensive dental or surgical procedures. Clinical photo of a clear acrylic Anterior Repositioning Splint (also known as an anterior bite plane). The device is U-shaped and fits over the upper teeth. It features a distinct downward slope or 'ramp' on the front incisors designed to position the mandible anteriorly. # ANTERIOR REPOSITIONING SPLINT **3 indications for internal derangement:** i) **Acute TMJ pain** ii) **Sleep bruxers who awaken with TMJ pain** iii) **Nocturnal TMJ locking** Klasser GD, Greene CS. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2009 Feb;107(2):212-23.   #### Indications for Internal Derangement 1. Acute TMJ pain. 2. Sleep bruxers who awaken with TMJ pain. 3. Nocturnal TMJ locking. Clinical photograph of an anterior view of a patient's mouth demonstrating the use of an Anterior Repositioning Splint. The image shows the clear acrylic splint positioned over the upper teeth (maxillary arch), extending posteriorly to cover the molars and premolars. The lower jaw is slightly open, revealing the mandibular incisors below the splinted maxillary arch. This visual demonstrates the appliance designed to treat internal derangement of the TMJ. Clinical photograph of an anterior view of a patient's mouth showing a different angle or perhaps a different stage of treatment involving an Anterior Repositioning Splint. Similar to the first photo, a transparent splint covers the upper teeth, but here it appears to be in occlusion with the lower teeth. The image provides a comparative view of how the splint fits within the dental arch. # ANTERIOR REPOSITIONING SPLINT ## Critics: Occlusal and skeletal changes with long-term use. *Tesco et al. Cranio 2004;22:209-219.* | Subject's Mouth Open | Mouth With Retainer | | :--- | :--- | | |   #### Clinical Concerns - **Critics:** Highlight the risk of permanent occlusal and skeletal changes associated with long-term use. Clinical photograph of a patient's mouth with the mouth open and cheeks retracted by a dental mirror or instrument. The image displays the occlusion of the upper and lower teeth, showing the alignment of the dentition. Clinical photograph of a patient's mouth with the mouth held open by a plastic cheek retractor. This view demonstrates the occlusal relationship between the upper and lower anterior teeth, illustrating the bite position. # NEUROMUSCULAR SPLINT Jaw muscle stimulators with surface EMG and jaw-tracking machines for the ideal vertical and horizontal position of the mandible: **“myocentric position”.¹** * Dental reconstruction at the new jaw position. * Neuromuscular mouthguards do not enhance competitive athletes.² ¹Cooper BC. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 1997 Jan;83(1):91-100. ²Cotter JA et al. J Strength Cond Res. 2017 Jun;31(6):1627-1635. ## K7x Evaluation System    #### Myocentric Position and Technology - **Methodology:** Uses jaw muscle stimulators, surface EMG, and jaw-tracking machines (such as the K7x Evaluation System) to determine the ideal "myocentric" vertical and horizontal position of the mandible. - **Clinical Application:** Dental reconstruction is performed at this new jaw position. - **Athletic Performance:** Research indicates neuromuscular mouthguards do not enhance the performance of competitive athletes. Photo of a grey medical device labeled 'J5 DENTAL TENS' with control knobs and display screen, representing a jaw muscle stimulator mentioned in the text. Photo of the K7x Evaluation System hardware unit with attached monitor displaying data, corresponding to the system title in the slide. Photo of a transparent mannequin head fitted with a metal frame apparatus for tracking jaw movement, illustrating the jaw-tracking machine concept. # NEUROMUSCULAR SPLINT ## OccluSense by Bausch  *(Image containing device, tablet showing occlusal analysis, and clinical scenario with a technician and patient in a dental office)* ## Noromed MES 9000  *(Image displaying a Noromed MES 9000 facility, including the unit console, scope/scanner, and related attachment)*     #### Diagnostic and Analysis Systems - **OccluSense by Bausch:** A system utilizing a device and tablet for digital occlusal analysis. - **Noromed MES 9000:** A diagnostic facility including a console, scanner, and related attachments for neuromuscular evaluation. Product rendering of the OccluSense device by Bausch, showing a white and blue scanner unit with a red occlusal splint being scanned. A tablet screen displays a colorful digital analysis of the upper and lower dental arches in green, yellow, and red heat-map style, indicating bite force or pressure distribution. Clinical photo demonstrating the use of the OccluSense system in a dental office. A technician wearing gloves uses a handheld scanner on a patient's mouth while viewing real-time occlusal analysis data (pie chart and 3D model) on a large monitor. Photo of a female patient undergoing neuromuscular evaluation using surface electrodes attached to her forehead and neck via a strap. This visual demonstrates the application setup for capturing muscle activity signals relevant to splint therapy. Hardware overview of the Noromed MES 9000 Musculoskeletal Evaluation System. The image shows the main console labeled 'MES 9000', two 'Noro-Track 360' sensor units, a vertical rack module, and a black suction cup attachment, illustrating the physical components used for EMG scanning and muscle testing. RB NEUROMUSCULAR SPLINT myotronics.com RB myotronics.com # Neuromuscular Splint <div style="color:red; font-weight:bold;">**REALITY !!!**</div> <div style="font-size:small; margin-top:20px;">Myotronic.com</div>  REALITY !!! Myotronic.com Clinical photograph of a transparent U-shaped neuromuscular splint with embedded metal wires for reinforcement. The device is displayed on a blue surgical drape background. A prominent red banner overlay with white text 'REALITY !!!' is positioned at the bottom center, emphasizing its real-world application as opposed to an idealized model. # NEUROMUSCULAR SPLINT ## Scientific Evidence for Neuromuscular Splint Therapy <mark>◆ Digital devices can't accurately recreate variations in jaw motion and muscle contractions.1</mark> <mark>◆ Neuromuscular mouthguards do not enhance competitive athletes.2</mark> <mark>◆ Evidence for the "Neuromuscular Dentistry" philosophy is lacking. 3, 4</mark> ^1 Farook et al. Clin Oral Investig. 2023 Feb;27(2):489-504. ^2 Cotter et al. J Strength Cond Res. 2017 Jun;31(6):1627-1635. ^3 Gonzalev et al. Oral Maxillofacial Surg Clin N Am 2008;20:211-220. ^4 Klasser GD, Okeson JP. J Am Dent Assoc. 2006 Jun;137(6):763-71. #### Research Summary - **Digital Limitations:** Digital devices cannot accurately recreate the complex variations in jaw motion and muscle contractions. - **Athletic Impact:** Neuromuscular mouthguards show no evidence of enhancing performance in competitive athletes. - **Philosophical Basis:** Scientific evidence supporting the "Neuromuscular Dentistry" philosophy is currently lacking. POSTERIOR BITE PLANE SPLINT **MORA** **Modified MORA** **Posterior Plane Splint** **Variations: mandibular orthopaedic repositioning appliances, modified MORA** Acrylic resin platforms over posterior mandibular teeth with lingual wire Hence disocclusion of anterior teeth and changes the vertical and horizontal maxillomandibular relationship Bodenham RS. Br Dent J. 1970 Jul 21;129(2):85-6. Smith SD. N Y State Dent J. 1978 Aug-Sep;44(7):278-85.  #### Design Variations - **Common Names:** MORA (Mandibular Orthopaedic Repositioning Appliance), Modified MORA, Posterior Plane Splint. - **Construction:** Acrylic resin platforms placed over posterior mandibular teeth, often connected by a lingual wire. - **Mechanism:** Causes disocclusion of anterior teeth and alters the vertical and horizontal maxillomandibular relationship. Clinical comparison figure displaying four variations of Posterior Bite Plane Splints. From left to right: 'MORA' (a white acrylic resin model with lingual wire), 'Modified MORA' (similar model showing disocclusion of anterior teeth), a transparent clear splint on a blue background, and an intraoral photo demonstrating the appliance in use causing separation of anterior teeth. # POSTERIOR BITE PLANE SPLINT ## Advocates: Increase physical strength ### 1. Seated Press * **Image:** [Woman lifting dumbbells] * **Finding:** No difference in power with seated press with MORA vs placebo splint * **Reference:** Moore et al. Phys Sportsmed. 1986 Dec;14(12):137-45. ### 2. Muscular Strength * **Image:** [Man holding football] * **Finding:** MORA has no effect on muscular strength compared to no splint or placebo splint * **Reference:** Yates et al. J Am Dent Assoc. 1984 Mar;108(3):331-3.   #### Claims Regarding Physical Strength - **Seated Press:** Studies show no difference in power during a seated press when using a MORA versus a placebo splint. - **Muscular Strength:** Research indicates the MORA has no significant effect on muscular strength compared to no splint or a placebo splint. Clinical photo of a woman in a gym setting performing a seated dumbbell press. The image illustrates the 'Seated Press' study mentioned in the text, showing the physical activity used to test for power differences between MORA and placebo splint treatments. Photo of an American football player in a red jersey holding a football, representing muscular strength or athletic exertion. This visual accompanies the finding that 'MORA has no effect on muscular strength compared to no splint or placebo splint', as cited from Yates et al. POSTERIOR BITE PLANE SPLINT **Adverse Effect:** posterior openbite  #### Adverse Effects - **Occlusal Risk:** Potential development of a posterior open bite. Clinical photo set demonstrating the adverse effect of a posterior bite plane splint: posterior openbite. The images show intraoral views with cheek retractors in place. The central and right panels clearly display an anterior-to-posterior vertical gap between the upper and lower posterior teeth, illustrating the malocclusion caused by the appliance. The left panel provides a comparative view showing the patient's dentition. **PIVOT SPLINT** **Variations:** fulcrum type splint **Hard acrylic** with single posterior contact in each of the quadrants **Advocates:** mandible fulcrums around the pivot hence unloading the articular surface.¹ • Treatment for osteoarthritis and internal derangements.²  1. Muhtarogullari M, Avci M, Yuzugullu B. Head Face Med. 2014 Oct 9;10:42.   #### Design and Indications - **Variations:** Fulcrum-type splint. - **Construction:** Hard acrylic with a single posterior contact point in each quadrant. - **Advocates' View:** The mandible is intended to fulcrum around the pivot, thereby unloading the articular surface. - **Clinical Use:** Proposed as a treatment for osteoarthritis and internal derangements. Medical line drawing illustrating the Pivot Splint mechanism. The image features a central figure of a person in profile with an inset circle highlighting the mandible and teeth to show bite registration. To the left is a magnified schematic of the temporomandibular joint (TMJ) showing the condyle and articular surface. Below the main illustration is a seesaw analogy with two children to represent the fulcrum action around the pivot point. Clinical photograph of a hard acrylic dental splint. A handwritten annotation in red ink reads 'Single contact' pointing to a specific posterior tooth area on the device, corresponding to the text description of single posterior contact points. # PIVOT SPLINT **Study:** Postulated that clenching on pivot = anterior downward condylar movement • Pivot prevents protrusion = upward condylar movement (0.3mm) • No distraction rather TMJ compression.^[3](https://www.researchgate.net/publication/278393515)_ • Adverse effect: posterior openbite 1 Moncayo S. J Orofac Pain. 1994 Spring;8(2):190-6. 2 ito et al. J Prosthet Dent 1986;56:478-84. 3 Seedorf et al. J Oral Rehabil 2007;34:34-40.   #### Research and Adverse Effects - **Condylar Movement:** Studies postulate that clenching on a pivot results in anterior downward condylar movement, while the pivot prevents protrusion (upward movement of ~0.3mm). - **TMJ Impact:** Evidence suggests the design causes TMJ compression rather than distraction. - **Adverse Effect:** Risk of developing a posterior open bite. Clinical photo showing a frontal view of the upper and lower dental arches. The teeth appear to be in occlusion with no significant visible gap between the posterior teeth. Clinical photo showing a close-up view of the posterior dentition with an evident posterior openbite. There is a clear vertical space between the maxillary and mandibular posterior teeth, consistent with the 'posterior openbite' adverse effect mentioned in the text. # HYDROSTATIC SPLINT ## Bilateral water filled plastic chamber on a maxillary appliance (Short-term) ### Advocates: mandible would automatically find the ideal position because it is not directed Lerman MD. J Am Dent Assoc. 1974 Dec;89(6):1343-50. https://aqualizer.com   #### Design and Theory - **Construction:** A maxillary appliance featuring bilateral water-filled plastic chambers (intended for short-term use). - **Advocates' View:** Suggests the mandible will automatically find an ideal position because it is not mechanically directed by the appliance. Composite figure showing three types of Aqualizer® hydrostatic splints: (left) AQUALIZER® ULTRA – a transparent plastic chamber over the maxillary arch with blue water-filled pads; (center-left) AQUALIZER® MINI – smaller version for teens/small mouths; (center-right) AQUALIZER® SLIM – slim design for sensitive patients. Each panel includes product name, image, and short description text. Clinical photograph showing an intraoral view of a patient’s upper teeth fitted with a transparent hydrostatic splint containing water-filled chambers. The appliance conforms to the dental arch, demonstrating bilateral coverage and adaptation to tooth structure as described in OCR context. #HYDROSTATIC SPLINT **Scientific Evidence:** Effectiveness of Aqualizer system in establishing the maxillomandibular relationship no better than chin point guidance. <img>Dental presentation slide titled "HYDROSTATIC SPLINT" showing a comparison between a green-labeled gin bottle (arrow pointing to it) and a water bottle (covered by a red X), referencing a study comparing Aqualizer system vs. chin point guidance for maxillomandibular relationship. Huth et al. Sci Rep. 2023 Dec 18;13(1):22535.     #### Scientific Evidence - **Effectiveness:** Research indicates the Aqualizer system is no better than chin point guidance in establishing the maxillomandibular relationship. Photo of a glass bottle labeled 'GREEN ANT GIN' with a green label and wooden cap. A gold-colored arrow pointing left with the word 'Gin' inside it. A blue rectangular box containing the text 'Water', overlaid by a large red X mark. Photo of a clear plastic water bottle with a blue cap. <div style="text-align: center;"> <b>BIOFEEDBACK SPLINT</b> </div> <div style="background-color: #505080; border: 1px solid #ccc; padding: 15px;"> <b>Design:</b> incorporation of a pressure sensor and microcontroller with intrabuccal vibratory stimulus <br> • Sensor triggered: **10-20kg** </div> <div style="background-color: #fff; padding: 15px;"> <center> </center> </div> <div style="background-color: #505080; border: 1px solid #ccc; padding: 15px;"> <b>Study:</b> BFS significantly reduces frequency and duration of burst <br> • Reduces pathological load on masticatory system </div> Bergmann et al. Clin Oral Investig. 2020 Nov;24(11):4005-4018.  #### Design and Function - **Mechanism:** Incorporates a pressure sensor and microcontroller that provides an intrabuccal vibratory stimulus when triggered (typically at 10-20kg of pressure). - **Study Findings:** Biofeedback splints (BFS) significantly reduce the frequency and duration of clenching bursts, thereby reducing pathological load on the masticatory system. Clinical photograph of a transparent blue biofeedback splint (labeled 'bruxane') designed for the upper dental arch. The image demonstrates the physical design incorporating internal components (likely sensors and actuators) relevant to the text description of pressure sensors and vibratory stimuli. <b>EXTRATERRESTRIAL SPLINTS</b> English: Universal Neuromuscular Immediate Relaxing Appliance (UNIRA) Lingual Ring Ri.P.A.Ra device English text on image: 5d, 4d, 3d, 5s, 4s, 3s, 2.   #### Alternative Device Designs - **Universal Neuromuscular Immediate Relaxing Appliance (UNIRA)** - **Lingual Ring Ri.P.A.Ra device** - **Reference markings:** 5d, 4d, 3d, 5s, 4s, 3s, 2. Figure showing two visual representations of the Universal Neuromuscular Immediate Relaxing Appliance (UNIRA): top panel displays a purple 3D CAD model of the appliance structure with vertical flanges and curved arch; bottom panel shows a clinical photo of the white UNIRA device in situ on a dental mannequin’s upper and lower teeth, demonstrating its intraoral placement for neuromuscular control. Figure displaying two views of the Lingual Ring Ri.P.A.Ra device: top right is a labeled photograph of the purple lingual ring appliance with callouts indicating positions 1–6 and segments 3d, 4d, 5d, 3s, 4s, 5s; bottom right is an intraoral clinical photo showing the clear/blue lingual ring positioned behind the mandibular teeth, illustrating its functional placement within the oral cavity. **AGENDA** - **OCCLUSAL SPLINTS REVISITED** - **OCCLUSAL SPLINTS DESIGN SECRETS** - **MECHANISMS OF ACTION** - **SCIENTIFIC EVIDENCE FOR OCCLUSAL SPLINTS** - **TAKE HOME MESSAGE**  #### Agenda - Occlusal Splints Revisited - Occlusal Splints Design Secrets - Mechanisms of Action - Scientific Evidence for Occlusal Splints - Take Home Message Agenda flowchart diagram illustrating a presentation sequence on Occlusal Splints. The visual features a stepped layout with five distinct nodes connected by downward-pointing arrows. The sequence begins at the top with 'OCCLUSAL SPLINTS REVISITED', followed by 'OCCLUSAL SPLINTS DESIGN SECRETS', then 'MECHANISMS OF ACTION' (highlighted in an orange box), 'SCIENTIFIC EVIDENCE FOR OCCLUSAL SPLINTS', and concludes with 'TAKE HOME MESSAGE'. A gold header bar labeled 'AGENDA' sits above the steps. <table> <colgroup> <col/> <col/> </colgroup> <thead> <tr> <th align="left" colspan="2"> 8 Explanations For Treatment Success: </th> </tr> </thead> <tbody> <tr> <td align="left"> • Alteration of the occlusal condition </td> <td align="right" style="text-align: center;"></td> </tr> <tr> <td align="left"> • Alteration of the condylar position </td> <td align="right"></td> </tr> <tr> <td align="left"> • Increase in the vertical dimension of occlusion </td> <td align="right"></td> </tr> <tr> <td align="left"> • Cognitive awareness </td> <td align="right"></td> </tr> <tr> <td align="left"> • Increase peripheral input to CNS hence decreasing motor activity </td> <td align="right"></td> </tr> <tr> <td align="left"> • Regression to the mean i.e. the natural fluctuation of symptoms </td> <td align="right"></td> </tr> <tr> <td align="left"> • Placebo effect </td> <td align="right"></td> </tr> </tbody> </table> #Only theories nothing confirmed  #### 8 Explanations For Treatment Success - Alteration of the occlusal condition - Alteration of the condylar position - Increase in the vertical dimension of occlusion - Cognitive awareness - Increase peripheral input to CNS hence decreasing motor activity - Regression to the mean i.e. the natural fluctuation of symptoms - Placebo effect *Note: These are only theories; nothing is confirmed.* Table titled '8 Explanations For Treatment Success:' listing eight theoretical mechanisms: Alteration of the occlusal condition, Alteration of the condylar position, Increase in the vertical dimension of occlusion, Cognitive awareness, Increase peripheral input to CNS hence decreasing motor activity, Regression to the mean i.e. the natural fluctuation of symptoms, and Placebo effect. A decorative icon with two silhouettes and a question mark is positioned on the right side of the table. # HOW DO SPLINTS WORK? ```mermaid graph TD A[Ideology] -->|Downward Pressure| B(Line) C[Confirmational Bias] -->|Upward Pressure| B ``` **OCCLUSAL SPLINTS: FACTS VS FICTION** #### How Do Splints Work? Mechanisms are often influenced by: - Ideology (Downward Pressure) - Confirmational Bias (Upward Pressure) **Occlusal Splints: Facts vs Fiction** **FICTION: TMJ UNLOADING** **Occlusal splint cannot “unload the TMJ”!** * Mandible is class III lever: cannot fulcrum at any point anterior to the masticatory muscles * **Fact:** can reduce or redirect the condylar loading **Effort = Muscle** **Hylander WL. AmJ Phys Anthropol. 1975 Sep;43(2):227-42.**  #### Fiction: TMJ Unloading **Occlusal splints cannot "unload the TMJ"!** - The mandible is a class III lever: it cannot fulcrum at any point anterior to the masticatory muscles. - **Fact:** Splints can reduce or redirect the condylar loading. - Effort = Muscle Labelled diagram illustrating the biomechanics of the mandible as a Class 3 lever. The horizontal bar represents the 'Mandible' and is labeled 'Mandible = Class 3 Lever'. On the left, an upward green arrow labeled 'Effort = Muscle' indicates muscle force. On the right, a downward blue arrow labeled 'Load' indicates biting force. A brown inverted triangle labeled 'TMJ' (Temporomandibular Joint) sits on top of the lever near the effort side, representing the fulcrum. Two grey boxes labeled 'Splint' are positioned above the lever: one near the TMJ and another over the purple double-headed arrows labeled 'Teeth', which span the distance between the teeth and the load. FACT: DECREASES MUSCLE ACTIVITY Occlusal splint can decrease nocturnal muscle activity. ¹,³ * Reflective response to “foreign objects” between teeth. * Nocturnal muscle activity returns to baseline after discontinuing splint use.³ * Even while using splint. * Muscle activity can increase in asymptomatic bruxers.⁴ **1 Dube et al. Dent Res 2004; 83(5): 398-403.** **2 Clark et al. J Am Dent Assoc. 1979 Oct;99(4):607-11.** **3 Sheikholeslam et al. J Oral Rehabil 1986;13(2):137-145.** **4 Krioth et al. J Prosthet Dent 1998;80:209-213.**  #### Fact: Decreases Muscle Activity Occlusal splints can decrease nocturnal muscle activity. - Reflective response to "foreign objects" between teeth. - Nocturnal muscle activity returns to baseline after discontinuing splint use. - Activity may return to baseline even while using the splint. - Muscle activity can increase in asymptomatic bruxers. Clinical photograph of a white occlusal splint (night guard) designed to fit over the upper dental arch. The image demonstrates the physical object discussed in the text as a device that decreases nocturnal muscle activity through a reflective response. ### Treatment for Headache - “Headache attributed to temporomandibular disorders” - >70% of TMD patients report headache - Sleep bruxism generated myalgia may trigger tension-type headache and migraine.¹ ¹ Jensen R. Cephalalgia 1999;19(6): 602-21.  #### Treatment for Headache - **Headache attributed to temporomandibular disorders:** - Over 70% of TMD patients report headache. - Sleep bruxism generated myalgia may trigger tension-type headache and migraine. Clinical photo of a woman wearing a hijab sitting at a desk with a laptop, holding her head in both hands as if experiencing a headache. The image visually supports the OCR text about headaches attributed to temporomandibular disorders (TMD) and sleep bruxism. **FACT: TREATMENT FOR HEADACHE** **Randomised controlled trial: 60 patients** **with TMJ arthralgia patients and tension-type headache** * *Stabilisation splint effective in headache improvement at 6 and 12 months compared to controls.* * **Ekberg et al. Swed Dent J 2002; 26: 115-24.** **Prospective controlled study: 60 patients** **with myogenous TMD and tension-type headache.** * **Stabilisation splint effective in headache improvement compared to control appliance at 10 weeks, 6 and 12 months.** * **Ekberg EC, Nilner M. J Oral Rehabil. 2006 Oct;33(10):713-21.** #### Clinical Evidence for Headache Management **Randomised controlled trial (60 patients):** - Subjects with TMJ arthralgia and tension-type headache. - Stabilisation splint was effective in headache improvement at 6 and 12 months compared to controls. **Prospective controlled study (60 patients):** - Subjects with myogenous TMD and tension-type headache. - Stabilisation splint was effective in headache improvement compared to control appliance at 10 weeks, 6, and 12 months. <h1>FACT: TREATMENT FOR HEADACHE</h1> **Double-blind**, randomized, placebo-controlled study to assess the separate or joint effects treatment of comorbid migraine and TMD. <div style="display: flow; flex-direction: row;"> <div style="flex-direction: column; gap: 1em;"> <img><br> 4 treatment groups: propranolol & stabilisation splint (22); placebo pill & stabilisation splint (23); propranolol & non-occluding splint (23); placebo pill & non-occluding splint (21). </div> <br> <div style="flex-direction: column; gap: 1em;"> <img><br> Migraine in women with TMD and migraine only improved when both conditions treated. (Goncalves et al. J Orofac Pain. 2013 Fall;27(4):325-35.) </div> </div> <div style="display: flex; gap: 1em;"> <img><br> <div style="display: flex; gap: 1em;"> Systematic review and meta-analysis: stabilisation splint decreases both headache frequency and intensity in TMD patients. (Manriquez et al. J Dent Anesth Pain Med. 2021 Jun;21(3):183-205.) </div> </div>    #### Comorbid Migraine and TMD Treatment **Double-blind, randomized, placebo-controlled study:** - Assessed separate or joint effects of treatment for comorbid migraine and TMD. - 4 treatment groups: 1. Propranolol & stabilisation splint 2. Placebo pill & stabilisation splint 3. Propranolol & non-occluding splint 4. Placebo pill & non-occluding splint - **Finding:** Migraine in women with TMD and migraine only improved when both conditions were treated. **Systematic Review and Meta-analysis:** - Stabilisation splints decrease both headache frequency and intensity in TMD patients. Clinical photo of a man holding his temples with both hands, eyes closed, and grimacing in pain. Red overlays highlight the temples/forehead area to indicate headache pain location. Clinical photo of a person in a green shirt resting their head on their hand, looking distressed or fatigued, illustrating symptoms associated with migraine or headache. Clinical photo of an older woman with her eyes closed and a slight smile, likely representing relief or recovery from headache treatment. # FICTION: TREATMENT OF TMJ INTERNAL DERANGEMENTS ## Misconceptions about the need to treat TMJ disc displacements. * Treatment of disc displacement with catching and locking is recommended. Williamson EH, Rosenzweig BJ. Cranio. 1998 Oct;16(4):222-5. **Advocates:** * Avoid progression from TMJ clicking to locking  #### Fiction: Treatment of TMJ Internal Derangements **Misconceptions about treating TMJ disc displacements:** - Treatment of disc displacement with catching and locking is recommended. - **Advocates suggest:** Avoid progression from TMJ clicking to locking. Anatomical diagram of the Temporomandibular Joint (TMJ) illustrating a 'Closed mouth position - anteriorly displaced disc'. The illustration labels the 'Articular eminence' and 'Condyle', showing the articular disc displaced anterior to the condyle. # FICTION: TREATMENT OF TMJ INTERNAL DERANGEMENTS Treatment versus no treatment did not change the outcome of patient adaptation. de Bont LG, Dijkgraaf LC, Stegenga B. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 1997 Jan;83(1):72-6. ## Facts: * Symptomatic relief ### When To Treat TMD? **Pain VAS** (Visual Analogue Scale) | Pain VAS | 0 | 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 | | :--- | :--- | :--- | :--- | :--- | :--- | :--- | :--- | :--- | :--- | :--- | :--- | | **Weeks** | | 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 | 11 | 12 | 13 | 14 | 15 | 16 | 17 |   #### Patient Adaptation and Pain Management - Treatment versus no treatment did not change the outcome of patient adaptation. - **Fact:** Splints provide symptomatic relief. **When To Treat TMD?** - Assessment via Pain VAS (Visual Analogue Scale) monitored over a 17-week period. Clinical photo of a clear, U-shaped dental appliance (likely an occlusal guard or splint) against a dark blue background. This device is used in the treatment of TMJ internal derangements. Line chart titled 'When To Treat TMD?'. The Y-axis represents 'Pain VAS' (Visual Analogue Scale) from 0 to 10, and the X-axis represents 'Weeks' from 1 to 17. A red line plots pain levels over time, showing fluctuations including a peak around week 4 and a trough around week 8. A green arrow points to the initial peak, and a red arrow points to the subsequent dip, illustrating the fluctuating nature of symptoms during the course of weeks. # FICTON: DEPROGRAM THE MUSCLES **Advocates**: Deprogram TMJ musculature and produce “ideal” jaw relationships * Study: Deprogramming splint and occlusal equilibration alleviated TMD and “minor changes in condylar position”. * Flawed study **Facts**: Muscle engram is learned pattern determined by the morphology of moving structures. * Changing the occlusal scheme (morphology) can change the engram.........But is this “THE” centric relation? 1Ramachandran et al. Cranio. 2021 Jul;39(4):294-302. 2Rinchuse DJ, Kandasamy S. J Am Dent Assoc. 2006 Apr;137(4):494-501. 3Rinchuse DJ, Kandasamy S. Am J Orthod Dentofacial Orthop. 2006 Feb;129(2):299-308  #### Fiction: Deprogram the Muscles - **Advocates:** Claim splints deprogram TMJ musculature and produce "ideal" jaw relationships. - **Flawed Study Claims:** Deprogramming splints and occlusal equilibration alleviated TMD and caused "minor changes in condylar position." **Facts:** - Muscle engram is a learned pattern determined by the morphology of moving structures. - Changing the occlusal scheme (morphology) can change the engram, but this does not necessarily establish "the" centric relation. Comparison figure showing three types of dental appliances: Anterior Bite Splint (left), B Splint (center), and Kois Deprogrammer (right). Each appliance is shown in a 3D model with the brand name 'Hector' visible on the surface. The labels below each image identify the specific type of splint or device. No evidence that ideal occlusal and skeletal treatment positions for dental patients based on "deprogramming" should be adapted for TMD patients Rinchuse DJ, Kandasamy S. J Am Dent Assoc. 2006 Apr; 137(4): 494-501. Rinchuse DJ, Kandasamy S. Am J Orthod Dentofacial Orthop. 2006 Feb; 129(2): 299-308.  No evidence that ideal occlusal and skeletal treatment positions for dental patients based on "deprogramming" should be adapted for TMD patients. Clinical photo of a patient's mouth showing teeth with an occlusal appliance (likely a bite guard or splint) in place. The image is relevant to the context of 'deprogramming' and TMD treatment positions as it visually demonstrates the application of such devices. # FICTION: IDEAL VERTICAL DIMENSION Advocates: occlusal splints reduce abnormal muscle activity and pain by restoring VDO “lost” to tooth wear and lost posterior support •Success attributed to increase VDO **Facts:** i. VDO is highly variable ii. Most individuals with decrease VDO do not have TMD Block LS. J Am Dent Assoc. 1947 Feb 15;34(4):253-60. Rugh JD, Drago CJ. J Prosthet Dent. 1981 Jun;45(6):670-5. Lassmann Ł, Calamita MA, Manfredini D. J Esthet Restor Dent. 2025 Jan;37(1):94-105.   #### Fiction: Ideal Vertical Dimension - **Advocates:** Claim occlusal splints reduce abnormal muscle activity and pain by restoring VDO "lost" to tooth wear and lost posterior support. Success is attributed to increased VDO. **Facts:** 1. VDO is highly variable. 2. Most individuals with decreased VDO do not have TMD. Clinical intraoral photograph showing the anterior teeth with a visible occlusal splint or night guard in place. The appliance covers the upper and lower incisors, appearing as a translucent, yellowish material that restores vertical dimension. Clinical intraoral photograph showing the anterior teeth without an appliance. This image demonstrates significant tooth wear (attrition) and loss of vertical dimension, serving as a visual contrast to the treated state shown in the adjacent photo. <html><body><h1>FICTION: IDEAL VERTICAL DIMENSION</h1><h2>Scoping Review: Concept of Vertical Dimension of Occlusion</h2><ul><li>No evidence for trial phase of new VDO to assess patient adaptation</li><li>Stability of VDO changes – does not cause or cure TMD</li></ul><h1>Almost everything we were taught about VDO is a myth!</h1><p>Block LS. J Am Dent Assoc. 1947 Feb 15;34(4):253-60.</p><p>Rugh JD, Drago CJ. J Prosthet Dent. 1981 Jun;45(6):670-5.</p><p>Lassmann Ł, Calamita MA, Manfredini D. J Esthet Restor Dent. 2025 Jan;37(1):94-105.</p></body></html> ```html <!DOCTYPE html> <html lang="en"> <head> <meta charset="UTF-8"> <meta name="viewport" content="width=device-width, initial-scale=1.0"> <title>Vertical Dimension of Occlusion</title> </head> <body style="font-family: Arial, sans-serif; padding: 20px; color: #333; direction: ltr;"> <h1 style="color: white; font-family: 'Bookman Old Style', serif; font-weight: normal;">FICTION: IDEAL VERTICAL DIMENSION</h1> <div style="display: flex; flex-wrap: wrap; gap: 20px; align-items: flex-start;"> <div style="flex: 1; min-width: 300px;"> <h2 style="background-color: #3366CC; color: white; border: 1px solid #3366CC; padding: 15px;">Scoping Review: Concept of Vertical Dimension of Occlusion</h2> <div style="background-color: #556677; color: white; border: 1px solid #3366CC; padding: 20px; margin-top: 20px;"> <ul style="list-style-position: inside;"> <li>No evidence for trial phase of new VDO to assess patient adaptation</li> <li>Stability of VDO changes – does not cause or cure TMD</li> </ul> </div> <h2 style="background-color: #880050; color: white; border: 1px solid #880050; padding: 20px; margin-top: 20px;">Almost everything we were taught about VDO is a myth!</h2> </div> <div style="flex: 0 0 auto;"> <img src="https://placehold.co/600x400/cccccc/333333?text=Dental+Articulator" alt="Dental Articulator" style="width: 100%; max-width: 500px; border: 1px solid #ddd;"> </div> </div> <div style="margin-top: 50px; font-size: 0.9em; color: #555;"> <p><strong>Block LS.</strong> J Am Dent Assoc. 1947 Feb 15;34(4):253-60.</p> <p><strong>Rugh JD, Drago CJ.</strong> J Prosthet Dent. 1981 Jun;45(6):670-5.</p> <p><strong>Lassmann Ł, Calamita MA, Manfredini D.</strong> J Esthet Restor Dent. 2025 Jan;37(1):94-105.</p> </div> </body> </html> ``` #### Scoping Review: Concept of Vertical Dimension of Occlusion - No evidence for a trial phase of new VDO to assess patient adaptation. - Stability of VDO changes does not cause or cure TMD. **Almost everything we were taught about VDO is a myth!** <table> <caption>THE SIMPLE FACTS OF OCCLUSAL SPLINTS</caption> <thead> <tr> <th style="text-align:center; background-color:#800040; color:white;"><strong>Fact</strong></th> <th style="text-align:center; background-color:#D4AF37; color:white;"><strong>Fiction</strong></th> </tr> </thead> <tbody> <tr> <td>Decrease / alter loading on TMJ</td> <td>Unload the TMJ</td> </tr> <tr> <td>Reduce muscle activity by foreign object</td> <td>Retrain the muscle to be less active</td> </tr> <tr> <td>Reduce headache intensity or frequency if triggered by sleep bruxism</td> <td>Relieve primary neurovascular or vascular headache</td> </tr> <tr> <td>Improve TMJ locking upon awakening related to sleep bruxism.</td> <td>Recapture displaced disc and prevent progression</td> </tr> </tbody> </table>   #### The Simple Facts of Occlusal Splints | Fact | Fiction | | :--- | :--- | | Decrease / alter loading on TMJ | Unload the TMJ | | Reduce muscle activity by foreign object | Retrain the muscle to be less active | | Reduce headache intensity or frequency if triggered by sleep bruxism | Relieve primary neurovascular or vascular headache | | Improve TMJ locking upon awakening related to sleep bruxism | Recapture displaced disc and prevent progression | Table titled 'THE SIMPLE FACTS OF OCCLUSAL SPLINTS' comparing 'Fact' and 'Fiction'. Columns include: Decrease/alter loading on TMJ vs Unload the TMJ; Reduce muscle activity by foreign object vs Retrain the muscle to be less active; Reduce headache intensity or frequency if triggered by sleep bruxism vs Relieve primary neurovascular or vascular headache; Improve TMJ locking upon awakening related to sleep bruxism vs Recapture displaced disc and prevent progression. Clinical photo of an occlusal splint device. The image shows a dental appliance with upper teeth in beige and a white lower border, designed to cover the teeth for TMJ relief. **THE SIMPLE FACTS OF OCCLUSAL SPLINTS** | Fact | Fiction | | :--- | :--- | | Disrupt neuromuscular engram that determine TMJ-fossa relationship | Produce ideal neuromuscular and occlusal relationship. | | Protect teeth and dental restorations from sleep bruxism | Permanently reduce or eliminate sleep bruxism | | Change the vertical dimension of occlusion | Establish “ideal” vertical dimension of occlusion |   #### The Simple Facts of Occlusal Splints (Continued) | Fact | Fiction | | :--- | :--- | | Disrupt neuromuscular engram that determine TMJ-fossa relationship | Produce ideal neuromuscular and occlusal relationship | | Protect teeth and dental restorations from sleep bruxism | Permanently reduce or eliminate sleep bruxism | | Change the vertical dimension of occlusion | Establish "ideal" vertical dimension of occlusion | Comparison table titled 'THE SIMPLE FACTS OF OCCLUSAL SPLINTS'. It contrasts 'Fact' (left column) and 'Fiction' (right column) regarding occlusal splints. Key points listed include: disrupting neuromuscular engrams vs producing ideal relationships; protecting teeth from bruxism vs permanently eliminating it; and changing vertical dimension of occlusion vs establishing an 'ideal' one. Clinical photo showing a close-up view of a patient's mouth with a clear occlusal splint in place. The splint covers both the upper and lower teeth, demonstrating its fit and position relative to the dental arches.   Header diagram labeled 'AGENDA' with a gold background and the 'RB' logo on the left. A stepped flowchart diagram illustrating the presentation agenda. It features five descending blocks connected by yellow arrows: 'OCCLUSAL SPLINTS REVISITED', 'OCCLUSAL SPLINTS DESIGN SECRETS', 'MECHANISMS OF ACTION', 'SCIENTIFIC EVIDENCE FOR OCCLUSAL SPLINTS' (highlighted in orange), and 'TAKE HOME MESSAGE'. ```html <table border="1"> <tr> <th colspan="3">OCCLUSAL SPLINTS FOR TEMPOROMANDIBULAR DISORDERS</th> </tr> <tr> <td> <b>Meta-analysis of RCTs (2025)</b> <br><br> Efficacy of occlusal splint compared to other conservative treatments for TMDs </td> <td> <b>18 articles: occlusal splints compared to other conservative treatments</b> <br><br> Not superior in pain management <br><br> Not superior in improvement mouth opening </td> <td> <b>Conclusion: occlusal splints</b> <br> <img src="https://placehold.co/200x100" alt="Splint image"> <br><br> <ul> <li>More effective than counseling in pain management</li> <li>Reduced the incidence of TMJ clicking</li> <li>More effective than placebo splints for pain and mouth opening</li> </ul> </td> </tr> </table> <b>Zhang et al. Oral Surg Oral Med Oral Pathol Oral Radiol. 2025 May;139(5):509-520.</b> ```  #### Meta-analysis of RCTs (2025) An analysis of 18 articles compared the efficacy of occlusal splints to other conservative treatments for Temporomandibular Disorders (TMDs). **Comparative Efficacy:** - Not superior in pain management when compared to other conservative treatments. - Not superior in improving mouth opening when compared to other conservative treatments. **Key Findings and Conclusions:** - More effective than counseling alone in pain management. - Reduced the incidence of TMJ clicking. - More effective than placebo splints for both pain reduction and mouth opening. *Source: Zhang et al. Oral Surg Oral Med Oral Pathol Oral Radiol. 2025 May;139(5):509-520.* Clinical photograph of a translucent occlusal splint designed for the mandibular arch. The image shows the anterior and posterior contours of the appliance, demonstrating its fit over the teeth. **OCCLUSAL SPLINTS FOR TMJ PAIN** | **Systematic Review & Meta-Analysis:** | | :--- | | **Efficacy of Conservative Treatments for Intragapsular TMJ Pain** | 13 RCTs (844 Participants) **Occlusal Splints effective for TMJ pain relief** **RB** Ferrillo et al. Cranio. 2025 Mar;43(2):258-274.  #### Systematic Review & Meta-Analysis: Intracapsular TMJ Pain A review of 13 Randomized Controlled Trials (RCTs) involving 844 participants examined the efficacy of conservative treatments for intracapsular TMJ pain. **Key Finding:** - Occlusal splints are effective for TMJ pain relief. *Source: Ferrillo et al. Cranio. 2025 Mar;43(2):258-274.* Flowchart diagram illustrating a systematic review on 'Occlusal Splints for TMJ Pain'. The flow consists of three connected blue boxes linked by a downward arrow: top box states 'Systematic Review & Meta-Analysis: Efficacy of Conservative Treatments for Intracapsular TMJ Pain'; middle box indicates '13 RCTs (844 Participants)'; bottom box concludes 'Occlusal Splints effective for TMJ pain relief'. To the right is an anatomical illustration of a temporomandibular joint with an occlusal splint inserted. # OCCLUSAL SPLINTS FOR MASTICATORY MUSCLE PAIN ```mermaid graph TD A["Systematic Review (2024)"] --- B["Stabilisation splint for muscle pain"] C["10 Articles"] --- D["Pressure pain threshold<br>Pain during chewing<br>Mouth opening<br>Spontaneous pain<br>Palpation pain"] E["Results"] --- F["Stabilisation splint (n=160) as effective as other treatment (n=209)"] B --- D D --- F ``` Honnef et al. Cranio. 2024 Nov;42(6):718-729.  #### Systematic Review (2024): Stabilisation Splints A systematic review of 10 articles evaluated the use of stabilisation splints for masticatory muscle pain. **Clinical Parameters Evaluated:** - Pressure pain threshold - Pain during chewing - Mouth opening - Spontaneous pain - Palpation pain **Results:** - Stabilisation splints (n=160) were found to be as effective as other treatments (n=209). *Source: Honnef et al. Cranio. 2024 Nov;42(6):718-729.* Anatomical diagram of the human head in lateral view showing masticatory muscles. Labels point to: Temporalis muscle (upper red muscle), Masseter muscle (lower red jaw muscle), and Zygomatic arch (bony structure above the cheek). Illustrates relevant anatomy for occlusal splint application. <!-- Flowchart: Occlusal Splints for TMD Based on Diagnosis --> **OCCLUSAL SPLINTS FOR TMD BASED ON DIAGNOSIS** | Diagnosis Type | Initial Appliance Selection | Progression / Contingency | Subsequent Appliance | Outcome/Loop | | :--- | :--- | :--- | :--- | :--- | | **Type I**<br>(Muscle Disorders) | Flat Plane Appliance | If refractory<br>Headache, Myofacial Pain | Anterior Bite Plane Appliance | **Green arrow (After symptoms resolve)** points back to Flat Plane Appliance | | **Type II**<br>(Disc Displacements) | Flat Plane Appliance | **Wilkes II with occasional locking** | Anterior Repositioning Appliance | If symptoms persist | **Green arrow (After symptoms resolve)** points back to Flat Plane Appliance | | **Type III**<br>(Joint inflammation) | Flat Plane Appliance | Severe Inflammation | Anterior Repositioning Appliance | **Green arrow (After symptoms resolve)** points back to Flat Plane Appliance | Greene CS, Menchel HF. Oral Maxillofac Surg Clin North Am. 2018;30(3):265-277.  #### Diagnostic-Based Appliance Selection 1. **Type I: Muscle Disorders** - Initial Selection: Flat Plane Appliance - Progression: If refractory (Headache, Myofascial Pain), transition to Anterior Bite Plane Appliance. - Follow-up: Return to Flat Plane Appliance after symptoms resolve. 2. **Type II: Disc Displacements** - Initial Selection: Flat Plane Appliance - Progression: For Wilkes II with occasional locking, transition to Anterior Repositioning Appliance if symptoms persist. - Follow-up: Return to Flat Plane Appliance after symptoms resolve. 3. **Type III: Joint Inflammation** - Initial Selection: Flat Plane Appliance - Progression: For severe inflammation, transition to Anterior Repositioning Appliance. - Follow-up: Return to Flat Plane Appliance after symptoms resolve. *Source: Greene CS, Menchel HF. Oral Maxillofac Surg Clin North Am. 2018;30(3):265-277.* Flowchart titled 'OCCLUSAL SPLINTS FOR TMD BASED ON DIAGNOSIS' illustrating treatment pathways for three diagnosis types. Each pathway (Type I Muscle Disorders, Type II Disc Displacements, Type III Joint inflammation) starts with a 'Flat Plane Appliance'. Arrows indicate progression to an 'Anterior Bite Plane Appliance' or 'Anterior Repositioning Appliance' based on refractory symptoms or severity. Green arrows loop back to the initial appliance after symptom resolution. Specific conditions like 'Wilkes II with occasional locking' and 'Severe Inflammation' are noted. # EFFECTS OF OCCLUSAL SPLINTS FOR SLEEP BRUXISM ## Systematic Review & Meta-analysis of RCTs (2024) **12 studies: 3 RCTs** (certainty of evidence: low/very low) **Does occlusal splint influence masticatory muscle function in sleep bruxers?** * Soft or hard splints did not affect muscle activity and bite force * Splints did not affect masticatory performance and muscle volume * Splints reduce tongue force Ferreira et al. Eur J Oral Sci. 2024 Apr;132(2):e12979. #### Systematic Review & Meta-analysis of RCTs (2024) This review included 12 studies (3 RCTs) with a low to very low certainty of evidence, investigating whether occlusal splints influence masticatory muscle function in sleep bruxers. **Key Findings:** - Soft or hard splints did not affect muscle activity or bite force. - Splints did not affect masticatory performance or muscle volume. - Splints reduce tongue force. *Source: Ferreira et al. Eur J Oral Sci. 2024 Apr;132(2):e12979.* # **OCCLUSION MATTERS?** Randomised controlled trial of 80 TMD subjects treated with occlusal splint vs palatal splint: At 6 & 12 months, 30% pain improvement: • **50%**: occlusal splint • **42%**: palatal (non-occluding) splint Both groups had improvement in function Nilsson H, Vallon D, Ekberg EC. J Oral Rehabil. 2011 Oct;38(10):713-21.   #### Comparative Trial: Occlusal vs. Palatal Splints A randomised controlled trial of 80 TMD subjects compared treatment with an occlusal splint versus a palatal (non-occluding) splint. **Results at 6 and 12 Months (30% Pain Improvement):** - **50%** of the occlusal splint group showed improvement. - **42%** of the palatal (non-occluding) splint group showed improvement. **Functional Outcome:** - Both groups demonstrated improvement in function. *Source: Nilsson H, Vallon D, Ekberg EC. J Oral Rehabil. 2011 Oct;38(10):713-21.* Visual representation of an occlusal splint, showing a dental cast with a full-coverage appliance designed to cover the upper teeth. Visual representation of a palatal (non-occluding) splint, showing a dental cast with a partial coverage appliance covering only the palate area without touching the opposing teeth. # Occlusion Matters? Non-occluding splints may be effective in TMDs (weak evidence).<sup>1,2</sup> Efficacy theories for non-occluding splint: • Placebo • Cognitive awareness When selecting a splint for TMD, “cover the occlusion” as occluding splints more effective for pain reduction.<sup>3,4</sup> --- ^1Dao TTT. et al. Pain. 1994 Jan;56(1):85-94. ^2Nilsson H, Vallon D, Ekberg EC. J Oral Rehabil. 2011 Oct;38(10):713-21. ^3Ekberg E, Vallon D, Nilner M. J Orofac Pain. 2003 Spring;17(2):133-9. ^4Alkhutari AS. et al. The Journal of prosthetic dentistry, 2012 126(1), 24-32. #### Efficacy of Non-Occluding Splints There is weak evidence suggesting that non-occluding splints may be effective in treating TMDs. **Theories for Non-Occluding Splint Efficacy:** - Placebo effect - Increased cognitive awareness **Clinical Recommendation:** When selecting a splint for TMD, it is advised to "cover the occlusion," as occluding splints are more effective for pain reduction. *Sources: Dao TTT. et al. 1994; Nilsson H. et al. 2011; Ekberg E. et al. 2003; Alkhutari AS. et al. 2012.* ```mermaid graph TD A[AGENDA] --> B[OCCLUSAL SPLINTS REVISITED] B --> C[OCCLUSAL SPLINTS DESIGN SECRETS] C --> D[MECHANISMS OF ACTION] D --> E[SCIENTIFIC EVIDENCE FOR OCCLUSAL SPLINTS] E --> F[TAKE HOME MESSAGE] ```  #### Presentation Overview - Occlusal Splints Revisited - Occlusal Splints Design Secrets - Mechanisms of Action - Scientific Evidence for Occlusal Splints - Take Home Message Flowchart diagram showing an agenda with five sequential steps connected by downward arrows. The top section is labeled 'AGENDA' in a gold banner. Below are four blue rectangular nodes: 'OCCLUSAL SPLINTS REVISITED', 'OCCLUSAL SPLINTS DESIGN SECRETS', 'MECHANISMS OF ACTION', and 'SCIENTIFIC EVIDENCE FOR OCCLUSAL SPLINTS'. The final node is orange and labeled 'TAKE HOME MESSAGE'. Arrows connect each step sequentially from top to bottom. **WHY DOES ONE PATIENT NEED ALL OF THESE SPLINTS?**  Why does one patient need all of these splints? Clinical photograph displaying a collection of various dental splints and orthodontic appliances arranged on a light blue background. The image includes clear acrylic night guards, yellow retainers, dark brown mouthguards, and U-shaped wire splints. The visual demonstrates the variety of devices used for different dental conditions. # HOW DO SPLINTS WORK? ### 8 Explanations For Treatment Success: * ~~Alteration of the occlusal condition~~ * ~~Alteration of the condylar position~~ * ~~Increase in the vertical dimension of occlusion~~ * Cognitive awareness * Increase peripheral input to CNS hence decreasing motor activity * Regression to the mean i.e. the natural fluctuation of symptoms * Placebo effect #### Explanations for Treatment Success 1. Alteration of the occlusal condition 2. Alteration of the condylar position 3. Increase in the vertical dimension of occlusion 4. Cognitive awareness 5. Increase peripheral input to CNS hence decreasing motor activity 6. Regression to the mean (the natural fluctuation of symptoms) 7. Placebo effect **TAKE HOME MESSAGE** * Occlusal splints are “oromandibular crutches” no different to orthotics * Avoid full-time wear and designs that may lead to change in occlusion * Mechanism of action of occlusal splints remains unknown * Occlusal splints protect teeth from bruxism but do not stop bruxism * Occlusal splints may be effective for TMD and headache triggered by sleep bruxism      #### Clinical Considerations and Efficacy - Occlusal splints are "oromandibular crutches" no different to orthotics. - Avoid full-time wear and designs that may lead to change in occlusion. - Mechanism of action of occlusal splints remains unknown. - Occlusal splints protect teeth from bruxism but do not stop bruxism. - Occlusal splints may be effective for TMD and headache triggered by sleep bruxism. A single visual node in a vertical list representing the first 'Take Home Message'. The node is a dark blue rectangular box with white text reading: 'Occlusal splints are “oromandibular crutches” no different to orthotics'. To the left of the text is a graphic icon resembling a golden gear or sunburst. This figure summarizes the conceptual definition of occlusal splints. A single visual node in a vertical list representing the second 'Take Home Message'. The node is a dark blue rectangular box with white text reading: 'Avoid full-time wear and designs that may lead to change in occlusion'. To the left of the text is a graphic icon resembling a golden gear or sunburst. This figure provides a clinical guideline regarding splint usage. A single visual node in a vertical list representing the third 'Take Home Message'. The node is a dark blue rectangular box with white text reading: 'Mechanism of action of occlusal splints remains unknown'. To the left of the text is a graphic icon resembling a golden gear or sunburst. This figure highlights a current limitation in medical knowledge regarding these devices. A single visual node in a vertical list representing the fourth 'Take Home Message'. The node is a dark blue rectangular box with white text reading: 'Occlusal splints protect teeth from bruxism but do not stop bruxism'. To the left of the text is a graphic icon resembling a golden gear or sunburst. This figure clarifies the specific therapeutic function versus the lack of curative effect of splints. A single visual node in a vertical list representing the fifth 'Take Home Message'. The node is a dark blue rectangular box with white text reading: 'Occlusal splints may be effective for TMD and headache triggered by sleep bruxism'. To the left of the text is a graphic icon resembling a golden gear or sunburst. This figure indicates potential indications for treatment efficacy. RB # OCCLUSAL SPLINT THERAPY Ramesh Balasubramaniam OAM THANK YOU!!! 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